Superior mesenteric arterial embolism: local fibrinolytic treatment with urokinase.

PURPOSE: To evaluate the efficacy of intraarterial urokinase in the treatment of superior mesenteric arterial (SMA) embolism. MATERIALS AND METHODS: Within 3 years, 10 patients (six men, four women; aged 62-82 years) with angiographically proved SMA emboli were selected on the basis of absence of peritoneal signs of intestinal necrosis at physical examination and normal abdominal plain radiographs to undergo local lysis with urokinase. RESULTS: The procedure was performed without complications in all 10 patients. The embolus was successfully lysed in nine patients (90%). Clinical success was achieved in seven patients (70%); however, in one patient laparotomy was required to confirm the clinical finding. None of these patients had recurrent embolism or postischemic intestinal stenosis during follow-up (mean, 11.2 months). The three remaining patients (30%) underwent laparotomy subsequent to failure of intraarterial treatment with urokinase. CONCLUSION: Fibrinolytic treatment with urokinase may be an effective alternative to surgical embolectomy in patients with SMA embolism without clinical or radiologic signs of intestinal infarction. In this small series, abatement of abdominal pain in the 1st hour of fibrinolytic treatment was the best indicator of clinical success. Pain persisted in patients with intestinal infarction.

Variceal hemorrhage: efficacy of transjugular intrahepatic portosystemic shunts created with Strecker stents.

PURPOSE: To evaluate the efficacy of transjugular intrahepatic portosystemic shunts (TIPS) in treatment of variceal hemorrhage. MATERIALS AND METHODS: Forty-five patients with cirrhosis underwent TIPS placement for treatment of acute (n = 12) or recurrent (n = 33) variceal hemorrhage. Shunts were created with Strecker stents. RESULTS: Shunts were established by deployment of stents in 42 patients. The portosystemic pressure gradient decreased from an average of 20.4 mm Hg +/- 5.4 to 9.2 mm Hg +/- 4.1. Complications included hepatic failure (n = 1), acute shunt thrombosis (n = 2), right jugular vein thrombosis (n = 1), bacteremia (n = 1), and stent misplacement (n = 1). Acute bleeding was controlled in 12 patients. The 30-day mortality rate was 2%; four other patients have since died. During follow-up (mean, 8.9 months), variceal bleeding recurred in six patients. Hepatic encephalopathy developed in six patients. Shunt stenosis or occlusion requiring further intervention occurred in 20 patients. CONCLUSION: TIPS are safe and effective in treatment of variceal hemorrhage; however, secondary interventions are often required to preserve shunt function.